Management of malignant pleural effusions

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Outcomes of bevacizumab combined with chemotherapy in lung adenocarcinoma-induced malignant pleural effusion

BACKGROUND

VEGF is critical in the pathogenesis of malignant pleural effusion (MPE). To understand the clinical benefits of antiangiogenic agents, the efficacy of chemotherapy containing bevacizmab was investigated in patients with lung adenocarcinoma-induced MPE.

METHODS

The data of lung adenocarcinoma patients with MPE treated with bevacizumab plus chemotherapy on day 1, every three weeks, for ≤ 6 cycles was retrospectively collected. Patients who achieved a response or stable disease were administered bevacizumab as maintenance therapy until progression. The primary outcomes of the study were MPE response rate (RR), MPE control rate, and pleural progression-free survival (PPFS), while the secondary outcomes were PFS, overall survival (OS), changes to the lung volume and thoracic cage, and safety profiles.

RESULTS

A total of 21 cases were collected, and all were evaluable for response, including 15 chemotherapy-naïve patients and 6 who experienced relapse. The median cycle of treatments was 7 (1-42) and 5 (2-6) for bevacizumab and chemotherapy, respectively. The MPE RR reached 81.0%. The MPE control rate at 6, 12, 24, 48, and 96 weeks were 95.2%, 90.0%, 89.5%, 73.7%, and 43.8%, respectively. Median PPFS was significantly longer than PFS (22.2 vs. 7.8 months; P = 0.044), and median OS was 25.8 months. Nineteen (90.5%) patients experienced lung re-expansion after treatment. Only one (4.8%) patient suffered thoracic volume decrease during treatment and the follow-up period. No unexpected adverse events were observed.

CONCLUSIONS

Bevacizumab combined with chemotherapy demonstrated efficacious, persistence, and safety in controlling lung cancer-induced MPE, indicating a potential superior therapeutic option.

The importance of serum and pleural fluid level of vascular endothelial growth factor (VEGF) and VEGF fluid/serum ratio in the differential diagnosis of malignant mesothelioma-related pleural effusion

Aim of the study

Vascular endothelial growth factor (VEGF) is one of the parameters that has been studied in differential diagnosis of malignant fluids. This study is aimed at evaluate applicability of serum, fluid VEGF level and fluid to serum VEGF ratio in the diagnosis of malignant pleural mesothelioma (MPM).

Material and methods

The patients with pleural effusion over age of 18, between 2011 and 2015 were included in the study. They were divided into three groups: group 1 – mesothelioma patients; group 2 – other malignancies; and group 3 – benign aetiologies. Group 1 and 2 were termed as the malignant group. Fluid, serum VEGF levels, and the ratio of fluid/serum VEGF level were studied to evaluate the fluid/serum VEGF ratio in all groups.

Results

Twenty cases with mesothelioma, 44 cases with other malignancies, and 20 cases with benign aetiologies were included in this study. No statistically significant difference was found according to serum VEGF levels for all groups, (group 1: 437 ±324 pg/ml, group 2: 354 ±223 pg/ml, group 3: 373 ±217 pg/ml, p = 0.836), while fluid VEGF levels showed a statistically significant difference (group 1: 3359 ±700 pg/ml, group 2: 2175 ±435 pg/ml, group 3: 1092 ±435 pg/ml, p = 0.041). The ratio of fluid to serum VEGF levels showed a difference, at the significance limit, between the malignant (group 1 and group 2) and benign (group 3) groups (8.83 ±1.29 vs. 4.57 ±1.07, p = 0.059) but showed a statistically significant difference between the mesothelioma and benign groups (12.11 ±1.68 vs. 4.57 ±1.07, p = 0.044).

Conclusions

The VEGF fluid/serum ratio may be an applicable parameter in the differential diagnosis of malignant fluids, especially MPM.

A modified experimental model of malignant pleural disease induced by lung Lewis carcinoma (LLC) cells

Background

Malignant pleural effusion resulting mainly from pleural metastases of lung adenocarcinoma has clinical relevance, being a sign of poor prognosis and low life expectancy. Experimental models can mimic the human condition, contributing to advances in current understanding of the mechanisms patients’ pleural fluid accumulation and possible therapeutic strategies. The objective of this study is to evaluate the role of different concentrations of Lewis lung carcinoma cells (LLC cells) at the time of induction of experimental MPE and the main effects on survival of animals.

Methods

C57BL/6 mice received intrapleural injection of 0.1, 0.5 or 1.5 × 10⁵ LLC cells and survival curve, biochemical and pathological analyses of pleural fluid and tissue were analyzed.

Results

Evaluation of weight loss, mobility and survival showed that animals that received 0.5 × 10⁵ cells maintained more stable condition up to day 14 and a gain of 6 days survival over mice that received the highest concentration.

Conclusion

This study may allow a better understanding the mechanisms involved in the development of malignant pleural effusion and it may be promising in evaluating therapy to avoid recurrence, as the best time to indicate pleurodesis or target therapies.

Silver nitrate versus tetracycline in pleurodesis for malignant pleural effusions; a prospective randomized trial

BACKGROUND

In this study, we aimed to investigate the effectiveness of silver nitrate (SN) versus tetracycline in pleurodesis among patients with malignant pleural effusion (MPE).

METHODS

In this prospective randomized clinical trial, patients with unilateral MPE candidate for pleurodesis were enrolled. The patients randomly allocated in two groups for receiving 20 mL 0.5% SN or 2.5 g tetracycline diluted in 30 cc normal saline and 0.1% lidocaine, through the chest tube. Patients were followed-up immediately (during 24 h) and 1-month after the procedure for evaluating recurrence of the pleural effusion using chest radiograph. They were clinically evaluated for chest pain and/or dyspnea and fever using a questionnaire that completed by the surgeon. The results were compared with two groups.

RESULTS

During this trial, 50 patients with MPE candidate for pleurodesis were selected and randomized into two interventional groups (25 patients in each group). Immediate and late recurrence of pleural effusion after pleurodesis were similar in two groups (P > 0.05). All patients in tetracycline group had fever and chest pain, but in SN group fever and chest pain were reported in 3 (12%) and 12 (48%) of patients, respectively (P < 0.05).

CONCLUSION

SN is at least as effective as tetracycline for MPE treatment. In addition, its side effects were lower than tetracycline. Other advantages of SN are its low cost, availability, and safety. For more accurate results, it is recommended to design further trials with larger sample size and with lower doses of both SN and tetracycline.

Interpretation of PET/CT findings in patients with advanced lung cancer who have undergone pleurodesis

A consensus has not yet been reached for the ideal moment to carry out pleurodesis in patients with malignant pleural effusion among the majority of centres, especially those which don’t specialise in oncologic treatment. The PET (positron emission tomography)/CT (computed tomography) used in the staging of patients with non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC) has caused controversy when used in the evaluation of therapeutical response and in detection of recurrence in patients with pleurodesis. For not distinguishing between inflammatory and neoplasic processes while using PET or CT, suspicion of pleural involvement can result in the indication for invasive diagnostic procedures or inadequate exchange of therapy. In such cases, the hypothesis of the inflammatory process must be included in the differential diagnoses for positive findings with the PET/CT in patients with NSCLC who have undergone pleurodesis, independently of time since the procedure. The reports of two patients with NSCLC have been presented in order to illustrate situations in which pleurodesis has been performed at the moment of diagnosis, outside of a cancer centre.

Successful use of indwelling tunneled catheters for the management of effusions in children with advanced cancer

BACKGROUND

Malignant pleural effusion (MPE) and ascites (MA) negatively impact quality of life of palliative patients. Treatment options are limited. This study's purpose is to examine the experience with indwelling tunneled catheters (ITCs) for management of MPE/MA in children with advanced cancer.

METHODS

Children with MPE/MA who underwent ITC insertion (2007-2012) were retrospectively reviewed. Clinical, procedural, complication and outcome details were analyzed.

RESULTS

PleurX® ITCs (n = 12) were inserted in eight patients (5-18 years) with sarcoma (11 MPE, 1 MA), achieving symptom relief and facilitating discharge home post ITC (median 2 days). Median survival following ITC was 51 days. There were two major complications: pain (n = 1), late site infection (n = 1), and five minor complications. Drainage ceased in four patients (pleurodesis/tumor progression). At time of death, six ITCs (five patients) were still in situ.

CONCLUSIONS

ITC appears to be a safe, effective treatment for MPE/MA in advanced pediatric cancer, achieving symptomatic relief and discharge home.

Malignant pleural effusion: medical approaches for diagnosis and management

Malignant pleural effusions (MPEs) are the second leading cause of exudative pleural effusions after parapneumonic effusions. In the vast majority of cases, a MPE signifies incurable disease associated with high morbidity and mortality. Considerable advances have been made for the diagnosis of MPEs, through the development of improved methods in the specialized cytological and imaging studies. The cytological or histological confirmation of malignant cells is currently important in establishing a diagnosis. Furthermore, despite major advancements in cancer treatment for the past two decades, management of MPE remains palliative. This article presents a comprehensive review of the medical approaches for diagnosis and management of MPE.

EMT markers in lung adenocarcinoma pleural effusion spheroid cells

Epithelial-to-mesenchymal transition (EMT) is a process in which cells undergo a developmental switch from epithelial to mesenchymal phenotype. This process has been related to embryologic morphogenesis but also to cancer progression and metastasis. The aim of the current study was to investigate the expression of EMT-related markers in adherent and spheroid cell cultures derived from malignant pleural effusions (MPEs) of patients affected by lung adenocarcinoma. On the basis of efficient in vitro propagation, six cases of MPEs were selected and analyzed by immunocytochemistry staining for EMT markers and by RT-PCR for transcription factors known to orchestrate EMT. EMT markers immunostaining showed in spheroids a statistically significant correlation between the loss of E-cadherin immunoreactivity and overexpression of N-cadherin (P < 0.001). Likewise loss of EpCAM epithelial marker was coincident with Vimentin overexpression (P < 0.001). RT-PCR analysis of transcription factors Snail, Slug, and Twist showed a highly variable expression, although a general trend to increase was observed. Importantly, in some selected cases it was possible to establish a precise relationship between spheroid formation, EMT switch and increased upregulation of the marker related to cancer stemness such as ALDH positivity. Therefore, MPE-derived cell cultures, while recapitulating the heterogeneity of lung cancer, are a suitable system to study the mechanisms at the basis of EMT and to understand its relationship with the generation of cancer stem cells.

Treatment of malignant effusion by oncolytic virotherapy in an experimental subcutaneous xenograft model of lung cancer

Background

Malignant pleural effusion (MPE) is associated with advanced stages of lung cancer and is mainly dependent on invasion of the pleura and expression of vascular endothelial growth factor (VEGF) by cancer cells. As MPE indicates an incurable disease with limited palliative treatment options and poor outcome, there is an urgent need for new and efficient treatment options.

Methods

In this study, we used subcutaneously generated PC14PE6 lung adenocarcinoma xenografts in athymic mice that developed subcutaneous malignant effusions (ME) which mimic pleural effusions of the orthotopic model. Using this approach monitoring of therapeutic intervention was facilitated by direct observation of subcutaneous ME formation without the need of sacrificing mice or special imaging equipment as in case of MPE. Further, we tested oncolytic virotherapy using Vaccinia virus as a novel treatment modality against ME in this subcutaneous PC14PE6 xenograft model of advanced lung adenocarcinoma.

Results

We demonstrated significant therapeutic efficacy of Vaccinia virus treatment of both advanced lung adenocarcinoma and tumor-associated ME. We attribute the efficacy to the virus-mediated reduction of tumor cell-derived VEGF levels in tumors, decreased invasion of tumor cells into the peritumoral tissue, and to viral infection of the blood vessel-invading tumor cells. Moreover, we showed that the use of oncolytic Vaccinia virus encoding for a single-chain antibody (scAb) against VEGF (GLAF-1) significantly enhanced mono-therapy of oncolytic treatment.

Conclusions

Here, we demonstrate for the first time that oncolytic virotherapy using tumor-specific Vaccinia virus represents a novel and promising treatment modality for therapy of ME associated with advanced lung cancer.

TLR2 in pleural fluid is modulated by talc particles during pleurodesis

The aim of this study was to examine the role of TLR2 molecule in pleural space during thoracoscopic talc pleurodesis period in patients with malignant pleural effusion. We analyzed TLR2 molecule in soluble form as well as on membrane of granulocytes in pleural fluid. Pleural fluid examination was done at three intervals during pleurodesis procedure: 1st—before the thoracoscopic procedure, 2nd—2 hours after the terminating thoracoscopic procedure with talc insufflation, 3rd—24 hours after the thoracoscopic procedure. We reported significant increase of soluble TLR2 molecule in pleural fluid effusion during talc pleurodesis from preoperative value. This increase was approximately 8-fold in the interval of 24 hours. The changes on granulocyte population were quite different. The mean fluorescent intensity of membrane TLR2 molecule examined by flow cytometry on granulocyte population significantly decreased after talc exposure with comparison to prethoracoscopic density. To estimate the prognostic value of TLR2 expression in pleural fluid patients were retrospectively classified into either prognostically favourable or unfavourable groups. Our results proved that patients with favourable prognosis had more than 3-fold higher soluble TLR2 level in pleural fluid early, 2 hours after talc pleurodesis intervention.

The dynamics of selected local inflammatory markers to talc in the treatment of malignant pleural effusions

BACKGROUND

Malignant pleural effusions accumulate in the space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall. Larger effusions compress the pulmonary parenchyma resulting in increasing dyspnoea. Treatment is always local and palliative. Among others, chemical pleurodesis using talc can be performed in selected patients. Talc is hydrated magnesium silicate (chemically H₂Mg₃(SiO₃)₄) and has been used for pleurodesis since 1935. Videothoracoscopic talc powder insufflation (talc poudrage) is the most effective.However, markers of inflammatory reactions to extraneous substances like talc are not fully understood. The aim of this study was to assess the course of local inflammatory changes in the pleural cavity after talc insufflation.

METHODS

The Department of Cardiac Surgery of the Faculty of Medicine and University Hospital in Hradec Kralove, treated 47 patients aged 65 on average; 29 males and 18 females with proven recurrent malignant pleural effusion of various aetiologies from January 2009 to December 2010. They were retrospectively divided into group A (40 patients) without recurring effusion, and group B (7 patients) with recurring effusion and the need for thoracentesis or chest drainage during the 9-month monitoring.

RESULTS

Major findings were made in soluble forms of cell receptors. Group B showed statistically higher levels of the anti-inflammatory form of sCD-163 receptor in pleural fluid before the talc poudrage. This showed limited ability to create an adequate inflammatory response to external stimuli. This group also showed lower levels of the inflammatory form of sTLR-2 receptor immediately after the talc insufflation. This revealed low local reactivity to external stimuli. The effect of the treatment was not influenced by morphologic tumour type. No statistically significant differences in postoperative complications were found. This confirmed the safety of both videothoracoscopy and treatment.

CONCLUSIONS

There was no correlation between the type of malignant affection and the outcome of the chemical pleurodesis. Patients with relapsing effusion have higher values of concentration of anti-inflammatory sCD-163 in pleural fluid even before the application of talc, and lower levels of concentration of inflammatory sTLR-2 immediately after application of talc.

Metabonomic classification and detection of small molecule biomarkers of malignant pleural effusions

To date, most research has been focused on the benign molecules in pleural effusions, and diagnosis of malignant ones still remains challenging. In the present study, targeting the small molecules as potential biomarkers to predict the malignancy of the effusions, the metabolic profiles of 81 clinical pleural effusions (41 malignant effusions from lung cancer and 40 benign ones) were investigated through a NMR-based metabonomic approach. In (1)H NMR analysis, a total of ten small molecules in the effusions were simultaneously determined. Significantly higher mean values of valine, lactate, and alanine and markedly lower signal intensities of acetoacetate, trimethylamine-N-oxide, and α- and β-glucose were observed in malignant pleural effusions compared with those in benign ones. DFA modeling of NMR spectra subjected to a validation allowed the malignant effusions to be discriminated from benign ones in both training and validation groups. Currently, the conventional clinical analyses on chemical constituents in effusions could not provide a reliable prediction of malignancy of the effusions; the present results revealed that the small molecules might serve as useful biomarkers for diagnosis of the effusions, and the present NMR-based metabonomic approach provided a valuable potential to rapidly and sensitively predict the malignancy of the pleural effusions.

Interventional radiology and the care of the oncology patient

Interventional Radiology (IR) is occupying an increasingly prominent role in the care of patients with cancer, with involvement from initial diagnosis, right through to minimally invasive treatment of the malignancy and its complications. Adequate diagnostic samples can be obtained under image guidance by percutaneous biopsy and needle aspiration in an accurate and minimally invasive manner. IR techniques may be used to place central venous access devices with well-established safety and efficacy. Therapeutic applications of IR in the oncology patient include local tumour treatments such as transarterial chemo-embolisation and radiofrequency ablation, as well as management of complications of malignancy such as pain, organ obstruction, and venous thrombosis.

Long-term outcome of pleurodesis with OK-432 in metastatic breast cancer: a new risk model for success from an analysis of 75 cases

BACKGROUND

Malignant pleural effusion is a common and devastating complication of metastatic breast cancer. This occurs in about 30% of patients with metastatic breast cancer during the clinical course, and chemical pleurodesis is sometimes performed to relieve dyspnea. However, the long-term outcome of pleurodesis and factors affecting successful pleurodesis have not been clarified.

OBJECTIVES

The aim of this analysis is to evaluate the long-term outcome of pleurodesis and to identify risk factors associated with success.

METHODS

Data on 75 patients who had undergone chemical pleurodesis with OK-432 for pleural effusion due to metastatic breast cancer were reviewed retrospectively. The primary outcomes were success rate and pleural progression-free survival (PPFS) rate.

RESULTS

The median duration of follow-up was 134 days (range 8-975 days). During this period, 22 patients re-accumulated pleural fluid. The overall success rate was 70.5%. The 4-, 8- and 12-week PPFS rates were 88.0, 84.0 and 78.7% respectively. Multivariate analysis identified three unfavorable factors that were independently associated with unsuccessful pleurodesis, including estrogen-receptor negative status, a 24-h drainage volume of more than 100 mL before extubation and NSAID use. The PPFS rate at median follow-up was 93.5% in the low-risk group (n = 41, 0 or 1 unfavorable factor) and 55.1% in the high-risk group (n = 34, 2 or 3 unfavorable factors). The difference between the PPFS curves of the two risk groups was statistically significant (P < 0.001).

CONCLUSIONS

Pleurodesis for metastatic breast cancer was efficacious in controlling malignant pleural effusion. Our simple new risk model warrants further studies.